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Sample Intramural Medical Information and Consent to Participate Form

This sample form is intended to serve as a guide for stakeholders to create a form that aligns with the policies and procedures in their respective school division/school.

 

PLEASE NOTE: FREEDOM OF INFORMATION- The information provided on this form is collected pursuant to the School Division’s education responsibilities as set out in the Education Act and its regulations. This information is protected under the Freedom of Information and Protection of Privacy Act and will be utilized only for the purposes related to the School Division’s Policy on Risk Management. Any questions with respect to this information should be directed to your school principal.

Parents/guardians are requested to complete this Intramural Medical Information and Consent to Participate Form and return it to their child/ward’s teacher.

Name of Student:
Grade:
Name of Teacher:

(Where your child’s/ward’s condition is confidential or requires further explanation you are requested to contact your child’s/ward’s teacher.)

Date of last complete medical examination:
Date of last tetanus immunization:

Is your child allergic to any drugs, food or medication/other?

Yes
No
If yes, provide details:
Medic Alert Information

Does your child/ward wear a medical alert bracelet?

Yes
No

Does your child/ward wear a neck chain?

Yes
No

Does your child/ward carry a medical alert card?

Yes
No
If yes, please specify what is written on it:
Oral and Visual Appliance

Does your child/ward wear eyeglasses?

Yes
No

Does your child/ward wear contact lenses?

Yes
No

Does your child/ward wear orthodontic appliance?

Yes
No

Does your child/ward have dental restorations (that is, crowns, bridges)?

Yes
No
Medical Conditions

Indicate if your child/ward has been diagnosed as having any of the following medical conditions and provide relevant details:

Allergies
Anaphylaxis
Asthma
Deafness
Epilepsy
Heart disorders
Type I Diabetes
Type II Diabetes
Other:
Relevant details:
Please provide relevant details and accommodations (for example, Plan of Care) to be made if your child cannot fully participate in physical activities:
Medications

Does your child/ward take any prescription drugs?

Yes
No
If yes, provide details:
What medication(s) should be accessible during the physical activity?
Who should administer the medication?
Physical Ailments

Indicate any physical ailments that apply and provide relevant details:

Arthritis or rheumatism
Chronic nosebleeds
Dizziness
Fainting
Headaches
Hernia
Orthopaedic conditions
Spinal conditions
Swollen, hyper-mobile or painful joints
Trick or lock knee
Head or back conditions or injuries (in the past two years)
Relevant details:
Concussion

Has your child/ward previously been diagnosed with a concussion?

Yes
No
How many times?
When was the last diagnosis? [month/day/year]
What medical advice was given by a medical doctor/nurse practitioner about participating in future physical activity?

If your child/ward is presently diagnosed with a concussion by a medical doctor/nurse practitioner, that was sustained outside of school physical activity, then documentation must be provided consistent with the school division policy/protocols around concussion recognition and management before the students returns to intramural activity.

Other Conditions

Please indicate any other condition that will limit participation or that the teacher should be aware of:
Elements of Risk Notice

I acknowledge and have read the Elements of Risk notice in the Intramural Parent/Guardian Letter.

Parent/Guardian Signature:
Date:
Intramural Activities/Clubs Permission

I give permission for my child/ward to participate in intramural activities/clubs.

Parent/Guardian Signature:
Date:
Question Mark

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